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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 19 Schematic representation of a body slice
Table 4.Overview of standard ultrasound scan planes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Standard scan planes Organs imaged
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Transverse scans
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Upper abdominal transverse scan
Right subcostal oblique scan Liver, gallbladder (Figs. 24, 30, 33)
Left subcostal oblique scan Left lobe of liver, stomach, spleen (Fig. 34)
Lower abdominal transverse scan Bladder, rectum, uterus, fallopian tubes, prostate
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Longitudinal scans
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Intercostal scan (porta hepatis scan,
shoulder–umbilicus scan)
Right flank scan Liver, kidney (Fig. 29)
Left flank scan Spleen, kidney (Figs. 31, 32)
Upper abdominal longitudinal scan Liver, stomach, pancreas, vessels (Figs. 28, 36)
Lower abdominal longitudinal scan Bladder, rectum, uterus, prostate (Fig. 40)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Liver, stomach, pancreas, vessels (Fig. 23)
(Fig. 39)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Liver, porta hepatis, gallbladder, bile ducts
(Figs. 25–27)
2
The Ultrasound Examination
17
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Scanning Protocol
..............................................................................................................
n
Beginners in particular should follow a systematic protocol in routine ultrasound
examinations to ensure complete coverage. The scan planes shown in Fig.
be imaged in the sequence indicated.
n
The examination proceeds in a counterclockwise direction. Longitudinal and
transverse scans are carried out continuously along the vessels, working from
the upper abdomen to the lower abdomen.
n
Possible sequence of standard scan planes:
x
Upper abdominal transverse scan
x
Right subcostal oblique scan
x
Right intercostal scan
x
Extended right intercostal scan
The Ultrasound Examination
x
Longitudinal paramedian scan
x
Right flank scan
x
Right midabdominal transverse scan
x
High left intercostal scan (high left flank scan)
x
Left flank scan
x
Left midabdominal transverse scan
x
Left subcostal oblique scan
x
Upper abdominal longitudinal scan
x
Lower abdominal longitudinal scan
x
Lower abdominal transverse scan
20 can
18
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Upper abdominal
transverse scan
Extended
intercostal scan
Right midabdominal
transverse scan
Left midabdominal
transverse scan
Right subcostal
oblique scan
Longitudinal
paramedian scan
High lateral
intercostal scan
(high left flank scan)
Left subcostal
oblique scan
Intercostal scan
The Ultrasound Examination
Right flank scan
Left flank scan
Upper abdominal
longitudinal scan
Lower abdominal
longitudinal scan
Fig. 20 Standard and supplemental scan planes
Lower abdominal
transverse scan
19
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Classification of Scan Planes, Sonographic Topography
..............................................................................................................
n
Relationship of the gallbladder to adjacent organs:
The Ultrasound Examination
a
b
Fig. 21a, b a The gallbladder fundus extends past the inferior border of the liver.
It lies to the right of the C-shaped duodenal loop and cranial to the right colic
flexure. b Visceral surface: The caudate lobe is bounded by the superior border of
the liver, falciform ligament, gallbladder, and vena cava. The quadrate lobe is
bounded by the inferior border of the liver, falciform ligament, gallbladder,
and portal vein
20
n
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Topographic anatomy of the pancreas and bile ducts:
a
2.1 Abdominal Sonography
2
The Ultrasound Examination
b
Fig. 22a, b a The splenic artery runs posteriorly and superiorly, the splenic vein
posteriorly and inferiorly. The tail of the pancreas extends toward the hilum of the
spleen, and the head of the pancreas lies within the C-shaped loop of the duodenum. The left lobe of the liver is anterior to the pancreas, and the aorta is posterior.
b Topographic anatomy of the bile ducts
21
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
n
Upper abdominal transverse scan:
The Ultrasound Examination
n
Anatomical guidelines for scanning the liver:
x
The right and left lobes of the liver are separated by the falciform ligament. The
ligament appears sonographically as an echogenic band (see Fig.
scans through the right and left lobes).
x
The separation of the two anatomical halves of the liver by the falciform ligament is most clearly appreciated when viewed from the posteroinferior direction.
x
Based on the segmental anatomy of the liver, a line drawn from the gallbladder
to the vena cava, marked by the interlobar fissure, separates the physiological
right and left lobes of the liver.
x
The gallbladder lies against the inferior surface of the right lobe of the liver.
x
To locate the caudate and quadrate lobes more easily, imagine the letter H
drawn on the visceral surface of the liver. One limb of the H is formed by a
line connecting the gallbladder and vena cava (which lie in grooves in the
liver); the other limb is formed by the falciform ligament. The crossbar is
formed by the porta hepatis where the portal vein divides into its right and
left main branches. The open areas of the H are occupied superiorly by the
caudate lobe and inferiorly by the quadrate lobe (see Fig.
surface of the liver).
n
Right subcostal oblique scan:
Fig. 23 The upper
abdominal transverse
scan displays the following structures from
anterior to posterior:
liver (L), splenic vein (SV),
pancreas (P), aorta (AO)
359), p. 252;
319), p. 231; visceral
Fig. 24 The probe is
placed below the right
costal arch and angled
laterally upward. The
beam is directed posterolaterally and superiorly.
The beam passes through
the liver (L) and gives a
longitudinal view of the
hepatic veins, which open
posteriorly into the vena
cava. RHV = right hepatic
vein, MHV = middle
hepatic vein, LHV = left
22
hepatic vein
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Right intercostal scan:
Fig. 25 The intercostal scan is placed on an imaginary line between the right
shoulder and the umbilicus. From this point the beam can be swept across the liver
(L) in a fan-shaped pattern. The kidney (K) is posterior
n
Extended right intercostal scan:
2
The Ultrasound Examination
Fig. 26 The extrahepatic bile ducts are defined in the porta hepatis scan by
sliding the probe toward the umbilicus. The probe can be slightly angled and
rotated to demonstrate the bile duct (BD), vena cava (Vc), and portal vein (Vp) in
approximate longitudinal sections. These structures are easier to define in left
lateral decubitus at full inspiration
23
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
n
Extended right intercostal scan:
The Ultrasound Examination
Fig. 27 Scanning in the same direction, the probe can be moved along the costal
arch to define the gallbladder (Gb) in longitudinal section. The gallbladder is most
easily located by keeping the inferior border of the liver in view while moving the
probe. BD = bile duct
n
Right longitudinal paramedian scan:
Fig. 28 The probe is oriented longitudinally and is placed lateral to the midline
in an intercostal space or below the costal arch. The liver (L) is displayed in
longitudinal section, and the shape of the (normally acute) inferior hepatic angle
can be evaluated. The fundus of the gallbladder (Gb) projects past the inferior
border of the liver. The vena cava (Vc) is displayed in longitudinal section and is
posterior to the liver. Vena cava filling can be evaluated in this plane
24
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Right flank scan:
Fig. 29 The flank scan is obtained by moving the probe laterally from the paramedian position. It is used to evaluate the pleural angle distal to the diaphragm (D)
and displays a longitudinal section of the kidney (K) posterior to the liver (L)
n
Right midabdominal transverse scan:
2
The Ultrasound Examination
Fig. 30 While viewing the kidney in longitudinal section, the examiner rotates
the probe to a midabdominal transverse position and slides it toward the midline.
The kidney (K) is displayed in cross-section posterior to the liver (L). The vascular
pedicle with the renal vein (Vr) and renal artery (Ar) can be identified from anterior
to posterior at the level of the renal hilum, and the ureter may also be seen. In thin
patients, one section may display the termination of the renal vein at the vena cava
(Vc), the origin of the renal artery from the aorta (Ao), and the gallbladder (Gb) at
the inferior border of the liver
25
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
n
High lateral intercostal scan (high left flank scan):
The Ultrasound Examination
Fig. 31 The probe is placed in an intercostal space cranial to the left flank and is
angled cephalad and medially to demonstrate the spleen (S) in longitudinal section. The upper pole of the spleen appears on the left side of the image, the lower
pole on the right side. The probe is rotated, slid, and angled until the longest
diameter is visualized. The length of the spleen and its thickness at the level of the
splenic hilum are measured
n
Left flank scan:
Fig. 32 As the probe is moved caudad from the high flank scan, the kidney (K)
appears in longitudinal section posterior to the spleen (S). The orientation of the
kidney, its posteriorly placed upper pole, and its anteriorly directed lower pole can
be clearly identified
26